During inpatient rehabilitation, IC is generally the preferred method of bladder management and several prospective studies have compared sterile techniques with traditional or clean techniques of IC (Charbonneau-Smith 1993; Prieto-Fingerhut et al.1997; Moore et al. 2006). Notably, Moore et al. (2006) and Prieto-Fingerhut et al. (1997) employed RCT designs and showed no statistically significant differences in the number of UTIs occurring in patients using the sterile technique versus the clean technique. Conversely, Charbonneau-Smith (1993) conducted a prospective trial and did find significantly reduced UTI rates for a sterile “no-touch” method as compared to historical controls undergoing a traditional sterile method. However, the nature of the historical comparison provides the possibility of confounding variables also affect this result. Both authors noted the greater expense associated with the sterile approach, making it the less attractive option in the absence of evidence for improved positive outcomes.

A meta-analysis of five RCTs comparing the impact of hydrophilic catheters on UTIs in people with SCI found a reduction in the number of UTIs (reduced by 64%) when the hydrophilic catheters were used (compared to non-coated catheters; Li et al. 2013). The coating on the hydrophlic catheters was also successful in reducing urethral trauma (reduced odds of hamturia by ~43%). Despite the general positive effect of hydrophilic catheters versus uncoated catheters, no significant difference was found in single studies for episodes of bacteriuria (Sutherland et al. 1996), number of UTIs (Vapneck et al. 2003) and frequency of symptomatic UTIs (Cardenas & Hoffman 2009). However, the reduced number of UTIs requiring antibiotics, significantly reduced UTI frequency and episodes of hematuria across multiple studies would generally advocate for the use of hydrophilic catheters.

An interesting RCT finding reported by Lavado et al. (2013) reflected a significant reduction of positive urinary cultures in patients randomized to 16 weeks of moderate aerobic physical conditioning compared to controls who were asked to maintain the daily life activities (Lavado et al. 2013). The main outcome of increased peak oxygen consumption in participants of the intervention group, suggested a correlation with an increased immune response attributed to the known beneficial effects of regular physical exercise.

As with all aspects of rehabilitation, a primary goal of bladder training within an inpatient stay is maximal patient independence and self-care. Wyndaele and De Taeye (1990) conducted a prospective control trial (n=73) in which the incidence of UTIs was examined following introduction of an initiative to promote self-catheterization among those with paraplegia on an SCI unit. Prior to this, catheterization was conducted by a specialized catheter health care team using a non-touch technique. Neither UTI rates nor the proportion of people achieving a state of bladder balance or those encountering complications of urethral trauma were significantly different between these two approaches. Interestingly, the introduction of patient self-catheterization also seemed to be a factor in the patients being ready for home visits much sooner in their rehabilitation stay.

Less information exists on the continued use of IC for individuals as they move into the community and live with SCI for a prolonged period of time. A prospective controlled trial was conducted by Yadav et al. (1993) comparing UTI incidence rates between those using a clean IC technique during inpatient rehabilitation with another group of patients continuing to use the same bladder management method and living in the community for 1-12 years. Similar rates of UTI (termed acceptably low by the authors) were found in both samples although there were differences in the types of bacteria causing UTIs between the individuals with SCI in the rehabilitation unit versus in the community.

Regardless of the approach to bladder management, and even if IC is used, the rate of UTI in the SCI population is still elevated relative to a population with neurologically normal functioning bladders. This is thought to be partly due to the residual volume of urine that may persist in the bladder following IC. Jensen et al. (1995) conducted a study in inpatient rehabilitation (n=12) correlating UTI incidence over the rehabilitation period with the average residual urine volume after IC. Correlations between UTIs and residual volumes were low and suggested little relationship or as the authors point out it may have been that residual volumes would have had to be reduced to negligible values to be responsible for a lower incidence of UTI compared to the mean values of 40±11 mL for hyperactive bladder or 19±7 mL for hypoactive bladder observed in this study.

Conclusion

There is level 1a evidence (from one meta-analysis of five RCTs; Li et al. 2013) that the use of hydrophilic catheters versus non-coated catheters is effective in reducing the incidence and occurrence of UTI and hematuria.

There is level 2 evidence (from two RCTs; Moore et al. 2006; Peta-Fingerhut et al. 1997) that there is no difference frequency of UTI between sterile and clean approaches to intermittent catheterization during inpatient rehabilitation; however, using a sterile method is significantly more costly.

There is level 4 evidence (from one prospective controlled trial; Wyndaele & De Taeye 1990) that there is no difference in UTI rates between intermittent catheterization conducted by the patients themselves or by a specialized team during inpatient rehabilitation.

There is level 4 evidence (from one prospective controlled trial; Yadav et al. 1993) that similar rates of UTI may be seen for those using clean intermittent catheterization during inpatient rehabilitation as compared to those using similar technique over a much longer time when living in the community.

There is level 4 evidence (from one pre-post study; Jensen et al. 1995) that differences in residual urine volume ranging from 0-153 ml were not associated with differences in UTI during inpatient rehabilitation.